INTRODUCTION

Definitions
Haemorrhage--bleeding
Escape of blood from a blood-vessel
Exsanguination- total loss of blood
Desanguination- major loss of blood

INTRODUCTION

Clinical Situation

Trauma /accidents
General operatiove interventions
Gynaecological procedures
Congenital coagulation disorders
Acquired coagulation disorders
Dic(disseminated intravascular coagulation)
Anticoagulants
Fulminent sepsis
Mof (multi organ failure)
Common surgical conditions pres w bleed
Intracranial haemorrhages/cva
Upper git bleed/haemetemesis and melena
Bleeding haeorrhoids
Chronic wounds
Anal fissures
Aneurysms

INTRODUCTION

Subjects importance
Haemorrhage is one of the basic problems and
considerations in surgery
From-trivial trauma or major abdominal organ injuries-to
- congenital and acquired coagulation disorders
A wide spectrum of problems involves haemorrhage
Transfusion of blood is the main remedy

INTRODUCTION

Physiology
BODYS SYSTEM OF HOMEOSTSIS
INTEGRITY OF EVERY SYSTEM
ANATOMICAL
FUNCTIONAL

PATHOLOGICAL BASIS OF
HAEMORRHAGE
BLEEDING CAN RESULT DUE TO:
LOSS OF INTEGRITY OF WALL
TRAUMA/OERATIONS

COAGULATION DEFECTS
CONGENITAL - H.PH
AQUIRED
-DIC

ETIOLOGY OF HAEMORRHAGE
CAUSES OF HAEMORRHAGE

INJURY /TRAUMA [+ operations]-It commonly

results in
tearing or cutting of a blood-vessel-integrity of
wall breached - Trivial OR Major

DISEASES

that alter coagulation

Congenital platelet defects
Coagulation factor defects
Acquired
scurvy
Sepsis
DIC

TYPES OF HAEMORRHAGE
Bleeding from an artery is of a bright red colour, and
escapes from the end of the vessel nearest the
heart in jets synchronous with the heart's beat
Bleeding from a vein is of a darker colour; the flow
is steady, the bleeding is from the distal end of the
vessel .
Capillary bleeding is a general oozing from a raw
surface .

TYPES OF HAEMORRHAGE
SPECIFIC TYPES
Bruise or ecchymosis .
Extravasation of blood /pouring out of
blood
into the areolar tissues, which become
boggy

Haematemesis and melena

Haemoptysis .
Haematuria
Epistaxis

TYPES OF HAEMORRHAGE

AMOUNT OF LOSS --MINOR/MAJOR

ACUTE/CHRONIC
ARTERIAL/VENOUS/CAPILLARY/MIXED
LOCALIZED/DIFFUSE
EXTERNAL/ INTERNAL
OVERT/OCCULT

Hemorrhage -four classes

American College of Surgeons' Advanced Trauma
Life Support (ATLS)
Class I Hemorrhage involves up to 15% of blood
volume. There is typically no change in vital signs
and fluid resuscitation is not usually necessary.
Class II Hemorrhage involves 15-30% of total
blood volume. A patient is often tachycardic
(rapid heart beat) with a narrowing of the
difference between the systolic and diastolic
blood pressures. The body attempts to
compensate with peripheral vasoconstriction.
Skin may start to look pale and be cool to the
touch. The patient may exhibit slight changes in
behavior. Volume resuscitation with crystalloids
(Saline solution or Lactated Ringer's solution) is
all that is typically required. Blood transfusion is
not typically required.

Hemorrhage -four classes

American College of Surgeons' Advanced Trauma
Life Support (ATLS

Class III Hemorrhage

involves loss of 30-40% of circulating
blood volume.
blood pressure drops, the heart rate
increases, peripheral perfusion (shock),
such as capillary refill worsens, and the
mental status worsens. Fluid
resuscitation with crystalloid and blood
transfusion are usually necessary.
Class IV Hemorrhage involves loss of
>40% of circulating blood volume. The
limit of the body's compensation is
reached and aggressive resuscitation is
required to prevent death.

EFFECTS OF
HAEMORRHAGE
Depend upon following:
Acute loss vs Chronic loss
The amount of loss
The compensatory mechanisms
General state of health

EFFECTS OF HAEMORRHAGE
Depends upon the amount of blood loss
Stages of Hypovolemia
Stage 1
Up to 15% blood volume loss (750mls)
Compensated by constriction of vascular bed
Blood pressure maintained
Normal respiratory rate
Pallor of the skin
Slight anxiety

EFFECTS OF HAEMORRHAGE
Stage 2
15-30% blood volume loss (750 - 1500mls)
Cardiac output cannot be maintained by
arterial constriction
Tachycardia >100bpm
Increased respiratory rate
Blood pressure maintained
Increased diastolic pressure
Narrow pulse pressure
Sweating from sympathetic stimulation
Mildly anxious/Restless

EFFECTS OF HAEMORRHAGE
Stage 3
30-40% blood volume loss (1500 - 2000mls)
Systolic BP falls to 100mmHg or less
Classic signs of hypovolemic shock
Marked tachycardia >120 bpm
Marked tachypnoea >30 bpm
Decreased systolic pressure
Alteration in mental status (Anxiety, Agitation)
Sweating with cool, pale skin

EFFECTS OF HAEMORRHAGE
Stage 4-----Shock
Loss greater than 40% (>2000mls)
Extreme tachycardia with weak pulse
Pronounced tachypnoea
Significantly decreased systolic blood
pressure of 70 mmHg or less
Decreased level of consciousness
Skin is sweaty, cool, and extremely pale
(moribund)

MANAGEMENT OF
HAEMORRHAGE

Prevention
Precautions during surgery
Operative method of control of
haemorrhage
Blood Transfusion

SURGICAL HAEMOSTASIS
NATURAL OR ARTIFICIAL
Natural CONTROLE/arrest of haemorrhage arises
from ;
(1) the coagulation of the blood itself,
(2) the diminution of the heart's action as in
fainting,
(3) changes taking place in the cut vessel
causing its retraction and contraction .

PATHOPHYSIOLOGY OF
HAEMORRHAGE
Bleeding
Hypovolaemia
Low cardiac output
Trachyacardia and shunting of blood from splanichnic
vessels by venoconstriction so as to maintain perfusion
of vital organ like, brain, heart, lungs, kidney.

Hypoxia
Activation of cardiac deperessants
Anaerobic metabolism and altered cell
membrane function causing influx of more
sodium, calcium, inside the cell and potassium
comes out of the cell.
hyponatraemic, hyperkalaemic, hypocalaemic
metabolic acidosis

Lysosomes of cell get lysed releasing powerful

enzymes which is lethal to cell itself
Sick cell syndrome
Platelets and coagulants are activated leading to
formation of small clot DIC & further bleeding.
Progressive haemodilution leading to total
circulatory failure

CLINICAL FEATURES OF HAEMORRHAGE..

Pallor, thirsty, cynosis.
Tachycardia, tachypnoea
Air hunger
Cold clammy skin due to vasocontriction.
Dry face, dry mouth and goose skin appearance
Rapid thready pulse, hypotention.
Oliguria.
Features related to specific causes.

Signs of significant blood loss

Pulse 100/ min
Systolic BP 100 mmhg
Diastolic BP drop on sitting or standing 10mmhg
Pallor / Sweating
Shock index (ratio of pulse rate to blood pressure)
1 ( cardiac index )

Effects of haemorrhage
Acute renal shut down
Liver cell dysfunction
Cardiac depression
Hypoxic effect
Metabolic acidosis
GIT mucosal ischaemia
Sepsis
Interstitial oedema, AV shunting in lung ARDS
Hypovolaemic shock - MODS